Cognitive/organic Mental Disorders

COGNITIVE / ORGANIC MENTAL DISORDERS COGNITIVE/PSYCHIATRIC DISORDERS With organic etiology With deficits in COGNITION and MEMORY Effects: Changes in levels of functioning and disturbed behavior

Delirium

Dementia

ReversibleAcute in onset

Chronic / Gradual in onset/ irreversible

#1 sign: Clouding of consciousness

#1 Sign: Progressive Or grand mal / tonicclonic seizure; Loss memory

Causes: Hyperthermia, Causes:Unknown sepsis such as (idiopathic) Encephalitis, meningitis, drug induced Withdrawal (alcohol & cocaine withdrawal)

SYMPTOMS OF DELIRIUM        

* Difficulty with attention * Easily distractible * Disoriented * May have sensory disturbances such as illusions, Misinterpretations or hallucinations * Can have sleep – wake cycle disturbances * Changes in psychomotor activity * May experience anxiety, fear, irritability, euphoria

Parkinson’s Disease  Dopamine

in the basal ganglia & extra-pyramidal system causes tremors (pill-rolling & resting), bradykinesia, cogwheel rigidity, shuffling gait, mask-like fascies. Progresses to depression & dementia, treated with L-dopa

ALZHEIMER’S DISEASE  Degenerative disease of the central nervous system characterized by premature senile retardation. Degenerative disorder of the cerebral cortex.  The etiology of Alzheimer’s disease is unknown  The most common non- traumatic cause of dementia is Alzheimer’s disease at 65, 10% of the population has Alzheimer’s; by 85, the percentage increases to half. Multiinfarct dementia is the second most common cause of non – traumatic dementia.

 The

main pathology is the of presence of senile plaques that destroys neurons leading to decreased acetylcholine.  NATURE: Gradual, progressive  Onset: Usually after 65 (2-4%); may begin at 40-65; may die within 2 yrs or 8-10 yrs if with total care.  The primary need of a patient with Alzheimer’s is Reorientation

4 CARDINAL SIGNS OF ALZHEIMER’S 1. Agnosia – sensory–inability to recognize objects/subjects  1st to forget: The name of an object  2nd to forget is the function of an object 2. Apraxia – sensory-inability for purposeful mov’t. ex. Tremors 3. Amnesia – 1st amnesia to appear: Anterograde amnesia –recent memory 2nd amnesia to appear: Retrograde – past  Tx: Reminiscing Group Therapy 4. Aphasia – sensory-inability for speech and communication

Predisposing/Contributing Factors:  Exact cause unknown  Hypotheses introduced: - Acetylcholine Alteration: Decrease in acetylcholine reduces the amount of neurotransmitter which results in disruption of cognitive process. - Accumulation of Aluminum: Studies show that aluminum accumulates in damaged areas of the brain.

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Alterations in the Immune System: Antibodies are being produced in the brain which causes a reaction against self it is called autoimmune

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Head Trauma: Head injuries

 Genetic

Factor: Pattern of inheritance

THREE STAGES OF ALZHEIMERS Early stage (Forgetfulness Stage: Mild) - The first symptom of Alzheimer’s disease is Progressive memory loss. This is followed by disorientation, personality changes, language difficulty, and other symptoms & dementia. - Findings that are observed in the early stages of Alzheimer’s disease are inappropriate affect, disorientation to time, paranoia, memory loss, and an impaired judgment.

Middle stage (Wandering Stage/Sundown syndrome) The patient is increasingly disoriented and completely unable to learn and recall new information. He may wander or become agitated or physically aggressive. He may have bladder incontinence and may require assistance with activities of daily living. Individual may be unable to recall major life events even the name of spouse..

Disorientation in the surroundings is common and the person may be unable to recall the day, season, and year. Sleeping becomes a problem. Symptoms worsen in the evening known as “SUNDOWNING”

 Late

stage (Kluver Bucy like Syndrome)

The patient may be unable to walk and is completely dependent on caregivers. He’s totally incontinent of bowel and bladder. He may even be unable to swallow and is at risk for aspiration. He’s unable to speak intelligibly.

In the late stages of Alzheimer’s disease it is better to go along with the patient’s reality rather than confront him with logical reasoning. Asking close ended simple questions that relate to his reality is non-threatening and calming. Note that the nurse’s response in a way that is congruent is the main concern. The individual may not recognize family members. There may be problems of immobility.

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Nursing Intervention: Milieu Therapy is needed: a CONSISTENT UNCHANGING & FAMILIAR ENVIRONMENT IS NEEDED to decrease chances of disorientation & confusion. In milieu therapy, patients plan and lead activities rather than the staff. Milieu therapy involves scientific manipulation of the environment that can influence improvement patient’s behavior

2. Store frequently used items within reach. 3.

Keep bed in unelevated position with soft padding if client has history of seizure and keep the rails up.

1.

Assign room near nurses’ station.

5. 6.

7. 8. 9.

Assist patient with ambulation. Keep dim light on at night. Decrease environmental stimulus. If patient is a smoker, stay with him/her at all times. Frequently orient patient to time, place and situation. If patient is prone to wander, provide an area in which the client is safe to wander.

10. Family

counseling about Alzheimer’s disease includes checking that pt is wearing ID bracelet when going out at all times 11. Soft restrain may be required if the client is disoriented and hyperactive as ordered by the physician. 12. Provision of simple, structured environment, ↓ choices 13. Consistency and ROUTINE in care to increase security; Brief, frequent contacts; reinforce reality-oriented comments

14. Allow

REMINISCING of past life / exploits / achievements. Reminiscing helps lessen the patient’s loneliness.

1.

REMEMBER THE 3 C’s for Alzheimer’s to DECREASE DISORIENTATION: Color, Calendar, Clock

SUMMARIZED DRUGS USED TO TREAT DEMENTIA NAME

DOSAGE RANGE AND ROUTE

NURSING CONSIIDERATI ON

Tacrine (Cognex) 40 – 160 mg orally per day divided into 4 doses

Monitor liver enzymes for hepatotoxic effects. Monitor for flu – like symptoms.

Donepezil (Aricept)

Monitor for 5 – 10 mg nausea, diarrhea, orally per dayand insomnia. Test stools periodically for GI bleeding.

Rivastigmine 3 – 12 mg for (Exelon) orally per dayMonitor nausea, vomiting, divided into 2 abdominal pain, and loss of doses appetite.

Monitor for 16 – 32 mg Galantamine nausea, vomiting, orally per dayloss of appetite, (Reminyl) divided into 2 dizziness, and syncope doses

BEST HERBAL DRUG FOR ALZHEIMERS:  Enhancing memory with ginkgo biloba  Ginkgo biloba, a plant extract, contains several ingredients that many believe can slow memory loss in people with Alzheimer’s disease, Research has shown that ginkgo produces arterial, venous, and capillary dilation, leading to improved tissue perfusion and blood flow. Adverse effects are uncommon but may include GI upset or using anticoagulants.

“The man who has done his best has done everything. The man who has done less than his best has done nothing.” “Success like happiness, is more than a destination – it is a venture; more than an achievement, it is an attitude.” “Be kind to every person you meet; everyone is fighting a difficult battle.” Thank you and Godbless!

EATING DISORDERS CAUSE: Unknown  Personality Disorder of Eating Disorders: Obsessive Compulsive Personality THEORIES OF CAUSATION: 1. Behavioral: Attention-seeking by rejecting foods; manipulation to gratify needs 2. Family interaction:  Ambivalent feelings towards mother  overprotection, rigidity, lack of personal boundaries and independence;  use of anorexia to avoid interpersonal conflicts

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The issue of CONTROL is a central one for the client with anorexia nervosa. It is believed that symptoms are caused by stressor that the adolescent perceives as a loss of control in some aspect of her life. Controlling intake and weight gain is a way the client establishes a sense of control over her life.

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3. Psychoanalytic: Regression to oral and anal developmental stage to avoid adolescent sexuality and independence 4. Medical: Genetic predisposition, increased catecholamines, hypothalamus dysfunction

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ANOREXIA -Amenorrhea  lanugo

-↓

15-20% ideal weight Defective defense mechanism: Denial Poor to fair prognosis

BULIMIA - Binge/purge syndrome Binge eating: Eating increased amounts of high calorie food in a short period of time. -2 binge-eating episodes or more per week for 3 months - fluctuation of body weight There is ACCEPTANCE - good prognosis  acceptance - Bulimic patients are usually aware of their abnormal behavior.

CHARACTERISTICS - vegetarian - All are females - Adolescent 11-17 yo - hoards/collects food - strenuous exercise - introvert - Patient’s with eating disorders are usually high achievers, perfectionist and preoccupied with food. OTHERS: Refusal to take meals → dramatic weight loss Anorexic patients usually suppress their appetite, which makes it difficult for the

CHARACTERISTICS - carbohydrate, ↑ caloric fast foods - 4 % are Boys - young adults - loves to cook -abuses laxatives/enema - extrovert

nurse to convince them to eat. Resistance to treatment; difficulty accepting nurturance & caring Feelings of loneliness and isolation Hypotension, bradycardia, hypothermia Secondary sexual organ atrophy; amenorrhea Reduced metabolism, reduced hormonal functioning; hypoglycemia; electrolyte imbalance Hyperactivity; Constipation; Leukopenia Skin problem: Hyperkeratosis (overgrowth of horny layer of epidermis)

Complications: Complications: #1 Cause of death: - esophageal cardiac varices dysrrhythmia --. - dental Hypokalemia  ECG carries  ST segment - callous depression & finger Prominent U wave - chipmunk face

STEP BY STEP NURSING STEP BY STEP DIAGNOSIS: NURSING 1. F/E imbalance DIAGNOSIS: 2. Fluid volume deficit – hypovolemic shock 1. F/E imbalance 3. Altered Nutrition less than 2. Fluid volume body requirement 4. Altered Body Image deficit – Change of body image hypovolemic shock causes difficulty in self3.Altered Nutrition esteem. Long term treatment for less than body anorexia/bulimia includes requirement outpatient family therapy sense of control over herself is a positive outcome in eating disorder.

NURSING INTERVENTION FOR EATING DISORDERS  DIETARY THERAPY → restoration and stabilization of nutritional and fluid balance  Feedings: Oral, IV or tubes; monitor hydration and electrolytes  Caring and nurturance when possible  Provide education 1) on growth & development and normal nutrition 2) Limit setting: Based on weight gain or loss, grant or restrict privileges  use behavioral contract to enforce limits

ASSESS AND EVALUATE:  Weight and % of normal body weight loss; weighing 3x a week: Same time, clothing and weighing scale. Limit activity based on weight gain: For wt. Loss – complete bed rest; gain less than 100 g- with bathroom privileges; more than 200 g- may ambulate in the hospital  Eating patterns: Amount, type of foods, time and place of eating, whether food is forced or followed by vomiting; Provide surveillance 30 min. to 1 hr after meals  Preventing the patient from using the bathroom for 2 hours after eating, prevents the patient from inducing vomiting.  Presence of anemia, hypotension, bradycardia, amenorrhea

PROVIDE A STRUCTURED ENVIRONMENT that offers safety and comfort and helps DEVELOP INTERNAL CONTROL→ reduces need to control by self-starvation.  Help client accept eating problem and set realistic, attainable short-term goals  Provide support is developing better outlets for emotional expression; Encourage outside interests not related to food  Provide teaching on therapeutic diet: Balanced, calories restriction to effect WEIGHT GAIN (1-2 pound per week)  Offer PRAISE for progress; accept lapses (behavior modification)  Instruct and support in behavioral modification program: 1) Control speed of eating – chewing food well; 2) Self monitoring w/ food diary; & 3) Praise/reinforce compliance  Best discharge plan for anorexic teen includes attending a support group

 DRUG

ADDICTION/NONALCOHOLIC SUBSTANCE ABUSE

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SUBSTANCE ABUSE TERMS AND DEFINITTIONS

TERMS

DEFINITIONS

Psychoactive substance Substance abuse

A substance that affects a person’s mood or behavior

Substance dependence

Continued use of a psychoactive substance despite the occurrence of physical, psychological, social, or occupational problems A range of physiologic, behavioral, and cognitive symptoms indicating that a person persists in using the substance, ignoring serious substance-related problems

Physiologic dependence Psychological dependence

Addiction Polysubstance

The emotional need or craving for a drug either for its effect or to prevent the occurrence of withdrawal symptoms A compulsion, loss of control, and progressive pattern of drug use; characterized by behavioral changes, impaired thinking, unkept promises to stop usage, obsession with the drug, neglect of personal needs, decreased tolerance, and physiologic deterioration Concurrent use of multiple drugs abuse An altered physiologic state resulting from the use of a psychoactive drug

Overdose

Accidental or deliberate consumption of a drug in a dose larger than is ordinarily used, resulting in a serious toxic reaction or death

Tolerance

Tolerance is the need for the increasing amount of a substance to produce its desired effect. It also refers to the decreasing effect of the drug.

Cross-tolerance

A state whereby the effect of a drug is decreased and greater amounts are required to achieve the desired effect because the person has become tolerant to a similar drug

Predisposition

Any factor that increases the likelihood of an event occurring

Potentiation

The ability of one drug to increase the activity of another drug when taken at the same time Any use of a drug that deviates from medical or socially acceptable use

Drug misuse Dual diagnosis

Blackout

The coexistence of a major psychiatric illness and a psychoactive substance abuse disorder An acute situation in which a person experiences a period of memory loss for actions as a direct result of using drugs or alcohol

Withdrawal

Discontinuation of a substance by a person who is dependent on it

Detoxificatio n

The process of withdrawing a person from an addictive substance in a safe manner

Toxic dose

The amount of a drug that produces a poisonous effect

Recidivism

Recovery

The tendency to relapse into a former pattern of substance use and associated behaviors The return to a normal state of health, whereby the person does not engage in problematic behavior and continues to meet life’s challenges and personal goals

Sobriety

Abstinence

Complete abstinence from drugs while developing a satisfactory lifestyle

Voluntarily refraining from activities or the use of substances that cause problems in the physiologic, psychological, social, intellectual, and spiritual arenas of a person’s life

ASSESSMENT FINDINGS 

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History. Academic or job failures, marital failures, stealing to support habit, personality change, violent acting out Physical Examination: Malnutrition; abdominal cramps; diaphoresis, yawning, lacrimation, rhinorrhea 10 hours after the last opiate injection; needle marks on arms along path of a vein (wearing of long- sleeves); nasal discharge with nasal septum perforation (cocaine) Social: Inability to maintain ADL and fulfill role responsibilities and obligations

GENERAL PRINCIPLES OF CARE: ALCOHOL DETOXIFICATION  3 A’s = Alcohol Withdrawal  Aversion Therapy (Pun 䁩 shment)  Aᡮtabuse (Disulfiram) = no effeɣt unless mixed with!alcohol  Dosage℺ Acutť phase = 500 mg in 1st 2 wks.  Main⁴enance Phase = 250"mg & ↓  ⁐zohibited Household items with alcohol: mouthwash, cough syrup/elixir,Ġvin 䁥 gar, fruiŴcakť, ųhaving cream, astringent, and toner, acetone/nail polish  Cough medicines and other over-the-counter medicines are alcohol-based and may cause antabuse reaction when it is combined with antabuse.  Antabuse may worsen renal damage thus it is contraindicated for patients with renal problems.

Effect of Antabuse with Alcohol  1. Nausea & Vomiting  2. Diarrhea  3. Intense headache  4. Abdominal cramps > Short term objective for an alcoholic: To stop/cut denial Long term objective: Abstinence (similar with STD/HIV/AIDS)  > # 1 group therapy for Alcoholics (12 step recovery program – AA (Alcoholic Anonymous) for victims of alcoholics: AL-ANON for alcoholic teens: ALATEEN

> Screening Questions for alcohol abuse: 1. When was the last time you have taken alcohol? 2. How much alcohol have you taken for the last 2448 hrs? 

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Goal in alcohol detoxification includes maintaining maximum physical integrity during withdrawal period.

CAGE SCREENING QUESTION FOR AN ALCOHOLIC C cut down alcohol (Do you need to cut down alcohol?) A annoyed (Are you annoyed when someone will ask you “Are you an alcoholic?) G guilty (Are you guilty of taking too much alcohol?) E eye opener (stimulant) Do you use an eye opener early in the morning to decrease the after effects of alcohol? 

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3 Stages of Alcohol Intoxication

I. Alcohol Serum Level = 0.04 -0.05% > unsteady gait  > ↓ social & sexual inhibition II. ASL = 0.08-0.1 or 100 mg/dl  > slurring of speech  > Fruity odor  similar to ketoacidosis  > Legal intoxication 

III. ASL = 0.15-0.2 – severe alcohol intoxication

Common Complications with History of Alcoholism 1. Liver Cirrhosis 2. Gastritis  inflammation 3. Pancreatitis 4. Wernicke’s Korsakoff’s  peripheral neuritis  lack of Vit. B1 (thiamine)  (Sx: Tingling sensation/numbness of extremities: Avoid electric blankets) *Confabulation or making up of stories is one of the initial manifestations of Korsakoff’s syndrome. 

Two categories of Wernicke’s Korsakoff’s:  A. Wernicke’s Aphasia / Receptive Aphasia: Problems in interpretation (temporal lobe)  B. Korsakoff’s Psychosis – irreversible (the best drug is Risperidone (Risperdal): It has decreased extrapyramidal symptoms (EPS) 4 Stages of Alcohol Withdrawal  I. Early/Initial – Fine tremors, restlessness, tachycardia, diaphoresis, hyperventilation & nervousness  II. Hallucination - hallucination of Alcohol withdrawal is TACTILE  III. Pre-seizure/RUM FITS mpending signs of Seizure 1. Epigastric pain (early sign in eclampsia) 2. High pitch cry/projectile 3. Eye pain/periorbital pain (scotomas) usually in eclampsia 4. Headache & Aura- ↑ ICP 5. Restlessness  cerebral hypoxia = ↓ 02 & glucose

IV. Delirium Tremens  Active Seizure = Grand mal/TonicClonic Delirium tremens is initially manifested by anxiety, restlessness, illusions, hallucinations and elevated vital signs.  Observation indicating a need to be included during endorsement to next shift in an alcoholic patient in the ER include observations of becoming fearful (delirium tremens)

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GENERAL PRINCIPLES OF CARE: DETOXIFICATION/OVERDOSE Maintain airway: Intubation (keep airway on hand), suction Start IV line Monitoring: BP, respiration, pulse, temperature, LOC Prevent and control seizures; Keep in calm, quiet environment Check for trauma, protect from injury Administer ordered drugs; Detoxify / treat overdose NALOXONE (NARCAN) – Pure antagonist to narcotics-induces withdrawal and stimulates respiration; DRUG OF CHOICE when in doubt the substance used because NALOPHINE (NALLIN), a partial antagonist to narcotics, will ↑ respiratory depression if barbiturates have also been used METHADONE – drug substitute used for acute withdrawal and long-term maintenance; changes an illegal to a legal drug, which is administered under supervision. Antidepressants block the ‘high’ from stimulant abuse Nutrition: High-calorie, high-protein, high-vitamin

PERVASIVE DEVELOPMENTAL DISORDERS  AUSTITIC DISORDER 

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A type of developmental disorder for an unknown; probable underlying problem: failure to develop satisfactory relationships with signifikant qdults mostly males Ŵalented in music or math # 1 screunyng0test – DᡮST (DenverĠDevelopmental Screening Tesᡮ) Autism is usuᡮlly diaᡮnᡮᡮed during tᡮe toddler stage. CHARAÃTERᡮSTICS: 1. ᡮlank stare 2. Repetitive movement: hťad banging  padded room/helmet 3. Likes to follow bright moving objects 4. Catatonic 5. Temper tantrums 6. Clings to inanimate objects

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ASSESSMENT FINDINGS: Disturbance in sense of self-identity, in ego system formation: Inability to distinguish between self and reality / environment → speaks of self in the third person Withdrawal from reality Lacks meaningful relationship with outside world; turns to inanimate objects and self-centered activities for security Personality alteration – adaptive, inhibitory, steering mechanisms due to profound interference in intellect SEVERE AUTISM – Severe apathy, Association looseness, Autistic thinking, Poor grasp of reality, Ambivalence, Poor communication skills, Poor interpersonal relations, Poor intellectual functioning

NURSING IMPLEMENTATION:  Provide consistent, routine ADL in familiar environment  Set consistent and firm limits for his behavior  Make physical contact on a regular basis. Accept the client’s need to push but still maintain regular contact.  Prevent acts of self-destructive behavior  Provide appropriate therapy:  Consistent loving home care is still favored over hospitalization; consistent care giver; never leave alone; and always provide safety.  Psychotherapy: Play, group, individual therapy  Primary treatment goal to facilitate the recovery of an autistic child should include playing with blocks not with balls .  #1 Occupational Therapy  #2 behavior modification  Behavior modification in an autistic child enables the nurse to modify the child’s maladaptive behavior.  Pharmacology: Tranquilizers and amphetamines to reduce symptoms

ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)  Disruptive behavioral disorder evident before 7 years old and lasting at least 6 months and characterized by hyperactivity and inattentiveness  THEORIES:  ↑ Norepinephrine, ↑ Serotonin  #1 Screening Test  DDST  CHARACTERISTICS:  1. Hyperactive  could not sit and stay in 15 minutes  2. ↑metabolism  fatigue  3. handwriting not legible  4. Easily agitated by noise & color (orange/yellow) ASSESSMENT  Severe inattentiveness with or without hyperactivity  Short attention span  Excessive impulsiveness  Squirming and fidgeting  Hyperactive  could not sit and stay in 15 minutes

NURISNG IMPLEMENTATION:         

Set realistic, attainable goals Provide firm, consistent discipline with opportunities to experience satisfaction and success Provide a structured environmentWith a balance of energy expenditure and quiet time With learning experience utilizing child’s ability With exercise in perceptual-motor coordination With LESS STIMULATION The priority needs of the child with ADHD are safety and provision of inadequate nutrition. Catching attention of a child with ADHD includes getting him to look at his mom & give him simple directions.

 Administer

drugs as ordered: RITALIN (methylphenidate) BEST GIVEN AFTER BREAKFAST or dextroamphetamine sulfate (Ritalin, the drug of choice for ADHD causes growth suppression, insomnia and suppression of appetite)  #1 Therapy: Occupational Therapy using behavior modification  DIET: ↑caloric content – finger foods  Vitamin B Complex ↑ appetite  Do not mix Caffeinated food/drinks with ACA/alcohol

MENTAL RETARDATION  Mild – IQ 50 – 70; can reach until 6th grade; self-supporting  Moderate – IQ 35 – 50, 2nd grade; able to acquire skills and need supervision  Severe – IQ 20 -35; can talk and communicate; can perform simple tasks and can learn elementary hygiene  Profound – IQ below 20; full-time care by caregiver; no academic skills, unable to relate verbally Causes:  Down syndrome  PKU  Rubella  Kernicterus  Anoxia  Lead poisoning  Meningitis – encephalitis  Neoplasms  Tay-sachs disease

Nursing interventions:  Goal: to promote optimum development within a family and community setting 1. Promote feelings of self-esteem, worth and security 2. Educate the parents about developmental stages and tasks; deal with child’s developmental, not chronological age.

 Goal:

to promote independence by setting realistic goals.

1. Teach basic skills in simple terms, with steps outlined 2. Use behaviour modification, as a method for behaviour control 3. Use the principles of repetition, reinforcement, and routine when providing for understanding and learning.

CHILD ABUSE DEFINITION: Physical abuse and emotional neglect; may include sexual abuse CAUSE: Exact-unknown; Present in all socioeconomic levels ASSESSMENT:  Obvious physical injuries, disturbance on parent-child interaction (Absence of PROTEST on admission of a toddler is a sign of abuse.)  Inconsistency of declaration of the type, location, cause of injury, discovery of undeclared / unreported fractures  Malnutrition / failure to thrive / emotional neglect  Sexual abuse signs: Genital bruises, lacerations; STDs

History:  Parents who were abused as kids  Other characteristics of abusive parents:  1) Tend to be young, immature, dependent  2) Low in self- esteem  3) Lacks identity  4) Expect child to provide them with love and care (PERSONAL ROLE THEORY of causation)  5) With incorrect concept of what the child is, and can do  6) With inadequate resources and support system  Abusive parents usually have low-self-esteem and has little social involvement.  Child abuse is common in the lower socioeconomic class.  The interaction between the abuse child and a mother provides a clue to the kind of relationship that this child has with his mother.

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In working with the mother of abused child, therapeutic use of self requires self awareness initially, therefore the nurse has to deal with her feelings first.

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Attendance to a parenting class is a step towards learning parenting skills, which are lacking in abusive parents.

NURSING IMPLEMENTATION      

FIRST: Meet physical needs; treat injuries MANDATORY: REPORTING of suspected cases to appropriate agency (SAVE EVIDENCES; TAKE PICTURES) EMOTIONAL SUPPORT to child: PLAY THERAPY to express feelings NONJUDGMENTAL ATTITUDE toward parents ROLE MODELING for parents who are encouraged to care for child DOCUMENTATION of ACTUAL FINDIGNS not interpretation nor opinion

POSSIBLE INDICATORS OF ELDER ABUSE Physical abuse indicators  Frequent, unexplained injuries accompanied by a habit of seeking medical assistance from various locations  Reluctance to seek medical treatment for injuries, or denial of their existence  Disorientation or grogginess indicating misuse of medications  Fear or edginess in the presence of family member or caregiver Psychological or Emotional abuse indicators  Helplessness  Hesitance to talk openly  Anger or agitation  Withdrawal or depression

Financial abuse indicators  Unusual or inappropriate activity in bank accounts  Signatures on checks that differ from the elder’s  Recent changes in will or power of attorney when elder is not capable of making those decisions  Missing valuable belongings that are no just misplaced  Lack of television, clothes, or personal items that are easily affordable  Unusual concern by the caregiver over the expense of the elder’s treatment when it is not the caregiver’s money being spent

Neglect indicators  Dirt, fecal or urine smell, or other health hazards in the elder’s living environment  Rashes, sores, or lice on the elder  Elder has an untreated medical condition is malnourished or dehydrated not related to a known illness  Inadequate clothing

Indicators of self-neglect  Inability to manage personal finances, such as hoarding, squandering, or giving away money while not paying bills  Inability to manage activities of daily living such as personal care, shopping, housework  Wandering, refusing needed medical attention , isolation, substance use  Failure to keep needed medical appointments  Confusion, memory loss, unresponsive  Lack of toilet facilities, living quarters infested with animals or vermin

Warning indicators from caregiver  Elder is not given opportunity to speak for self, to have visitors, or to see anyone without the presence of the caregiver  Attitudes of indifference or anger toward the elder  Blaming the elder for his or her illness or limitations  Defensiveness  Conflicting accounts of elder’s abilities, problems, and so forth  Previous history of abuse or problems with alcohol or drugs.

Rape Essential elements necessary to define an act of rape:  Use of threat/force  Lack of consent of the victim  Actual penetration of the penis into the vagina Different kinds of rape:  Power – compensation for low self-esteem  Anger – means of retaliation  Sadistic – errotization of sexuality Principles of Nursing care:  Provide safety and security  Preservation of evidence  Rape trauma counseling

Rape trauma syndrome:  Acute phase  Denial  Heightened anxiety  Stage of reorganization Battered Wife Syndrome  Characteristics of abusive husband:  They usually come from violent families.  They are immature, dependent and non-assertive.  They have strong feelings of inadequacy. Phases:  Tension building phase  Acute battering incident  Aftermath/honeymoon stage

ASSESSMENT FACTORS Influencing Assessment 1. Client participation/Feedback 2. Client’s Health Status 3. Client’s Previous Experiences/Misinterpretation About Health Care 4. Client’s Ability to Understand 5. Nurse’s Attitude and Approach

How To Conduct The Interview Environment 2. Input From Family and Friends 1.

Content of the Assessment 1. History – age, developmental stage, cultural/spiritual beliefs, beliefs about health and illness, client and family history

General Appearance and Motor Behavior – overall appearance including dress, hygiene, and grooming, posture, eye contact, facial expression, any unusual tics or tremors Specific terms used: automatisms, psychomotor retardation, waxy flexibility 3. Mood and Affect –terms: blunted affect, broad affect, flat affect, inapprorpaite affect, restricted affect, labile mood 4. Thought Process and Content – speech and speech patterns 2.

terms used: circumstantial thinking, delusion, flight of ideas, ideas of reference, loose associations, tangential thinking, thought blocking, thought broadcasting, thought insertion, thought withdrawal, word salad 5. Sensorium and Intellectual Process Orientation to 3 spheres,date, day and year, person, place and time and 4th sphere => situation Memory – recent and remote

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6. 7.

Ability to concentrate – spell word world backwards, serial 7s, repeat days of wee backwards, 3-part task Abstract thinking and intellectual abilities – proverb Sensory-Perceptual Alterations – hallucinations, illusions Judgment and Insight – judgmentability to interpret one’s environment and situation correctly and to adapt one’s behavior and decisions accordingly

ask hypothetical questions Insight – ability to understand the true nature of one’s situation and accept some personal responsibility for that situation – ability to realistically describe his strengths and weaknesses of behavior 8. Self-Concept - personal worth and dignity, body image, emotions 9. Role and Relationships

“Do you feel close to your family? “Do you have or want a relationship with a significant other?” “Are your relationships meeting your needs for companionship or intimacy?” “Can you meet your sexual needs satisfactorily?” “Have you been involved in any abusive relationships?” 10. Physiologic

and Self-Care Considerations Nutrition, hydration, sleep and rest

Psychological Tests – intelligence tests, personality tests 12. Psychiatric Diagnoses DSM–IV-TR-(uses Multi-axial System tp provide a format for a complete psychiatric diagnosis): Axis I: Clinical D/os, other conditions that maybe a focus of clinical attention Axis II: Personality D/os, mental retardation Axis III: General Medical Condition (GMC) Axis IV: Psychosocial and Environmental problems Axis V: Global Assessment of Functioning/ GAF (0-100) 11.

“Of the ten rules for success, the most important is hard work. The other nine are more work.” “Success like happiness, is more than a destination – it is a venture; more than an achievement it is an attitude.” “Be kind to every person you meet; everyone is fighting a difficult battle.” Thank you and God bless!